Home About us Editorial board Search Ahead of print Current issue Archives Submit article Instructions Subscribe Contacts Login 
Journal of Obstrectic Anaesthesia and Critical Care
Search articles
Home Print this page Email this page Small font size Default font size Increase font size Users Online: 525

 Table of Contents  
CASE REPORT
Year : 2015  |  Volume : 5  |  Issue : 1  |  Page : 30-32

Peripartum management of patient with a rare combination of two bleeding diatheses: Recognizing active role of anesthesiologists during preparatory preemptive prepartum multi-disciplinary conference


Department of Anesthesiology, Wayne State University, Detroit Medical Center, Detroit, Michigan, USA

Date of Web Publication15-Apr-2015

Correspondence Address:
Dr. Vitaly Soskin
Box No: 162, 3990 John R, Detroit, MI 48201
USA
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2249-4472.155197

Rights and Permissions
  Abstract 

To provide optimal medical care to our patients, it is crucial that all members of operating room team have clear understanding of patients' medical needs and the risks associated with their upcoming surgeries. Multi-disciplinary meetings to establish the best treatment options regarding patient care are not new to medicine. We hereby present a case in which an obstetric patient with a rare combination of two bleeding diathesis was managed using a similar multi-disciplinary approach. A 21-year-old pregnant patient with known von Willebrand's disease type I and platelet storage pool disorder (dense granule deficiency type: Decreased number of granules per platelet) presented to her hematologist for counseling regarding her current pregnancy. Decision was made to convene a multi-disciplinary conference with the panel inclusive of personnel from anesthesiology, adult hematology, pediatric hematology, pediatrics, maternal fetal medicine, obstetrics, pathology and blood bank services along with the patient and her family. The primary concerns of anesthesiologists were whether the patient with rare bleeding diathesis combination can have neuraxial analgesia-anesthesia and how likely the patient may have severe bleeding complications requiring massive blood transfusion protocol. As patient's von Willebrand factor activity was normal (>150%) secondary to pregnancy but platelet function was impaired, the hematologist's recommendations were that patient should receive transfusion of 5 units random donor platelets prior to labor epidural catheter insertion and 5 units random donor platelets prior to removal of epidural catheter left-in-situ for 24 h postdelivery. Anesthesiologists as perioperative physicians are in a unique position to actively participate in multi-disciplinary approach to perioperative patient care. Complex patient scenarios wherein multiple clinicians are concurrently managing these patients can benefit the most from this approach.

Keywords: Bleeding diatheses, peripartum management, prepartum multi-disciplinary conference, role of anesthesiologists


How to cite this article:
Kangas J, Gupta D, Paruchuri S, Soskin V. Peripartum management of patient with a rare combination of two bleeding diatheses: Recognizing active role of anesthesiologists during preparatory preemptive prepartum multi-disciplinary conference. J Obstet Anaesth Crit Care 2015;5:30-2

How to cite this URL:
Kangas J, Gupta D, Paruchuri S, Soskin V. Peripartum management of patient with a rare combination of two bleeding diatheses: Recognizing active role of anesthesiologists during preparatory preemptive prepartum multi-disciplinary conference. J Obstet Anaesth Crit Care [serial online] 2015 [cited 2019 Dec 16];5:30-2. Available from: http://www.joacc.com/text.asp?2015/5/1/30/155197


  Introduction Top


One of the fundamental truths as anesthesia providers is that we never work alone. To provide optimal medical care to our patients, it is crucial that all members of operating room team have clear understanding of patients' medical needs and the risks associated with their upcoming surgeries. This is true in all hospital settings but even more so in obstetric patients on labor and delivery floors because a single patient may be seen and managed by multiple residents, obstetricians, anesthesiologists and nurses throughout her hospital stay. Multi-disciplinary meetings to establish the best treatment options regarding patient care are not new to medicine. Tumor boards are a well-established example, which brings together radiologists, pathologists, radiation oncologists, medical oncologists and onco-surgeons to openly discuss risks and benefits of possible treatment options. [1],[2] We hereby present a case in which an obstetric patient with a rare combination of two bleeding diathesis was managed using a similar multi-disciplinary approach.


  Case Report Top


A 21-year-old pregnant patient with known von Willebrand's disease (vWD) type I and platelet storage pool disorder (dense granule deficiency type: Decreased number of granules per platelet) presented to her hematologist for counseling regarding her current pregnancy. She previously had minor surgeries without complication, although she had received prophylactic platelet transfusions perioperatively. Decision was made to convene a multi-disciplinary conference with the panel inclusive of personnel from anesthesiology, adult hematology, pediatric hematology, pediatrics, maternal fetal medicine, obstetrics, pathology and blood bank services along with the patient and her family. A comprehensive plan was discussed, formulated and agreed that was then placed in her electronic medical record [Figure 1]. The primary concerns of anesthesiologists were whether the patient with rare bleeding diathesis combination can have neuraxial analgesia-anesthesia and how likely the patient may have severe bleeding complications requiring massive blood transfusion protocol. As patient's von Willebrand factor (vWF) activity was normal (>150%) secondary to pregnancy but platelet function was impaired, the hematologist's recommendations were that patient should receive transfusion of 5 units random donor platelets prior to labor epidural catheter insertion and 5 units random donor platelets prior to removal of epidural catheter left-in-situ for 24 h postdelivery. However, vWF/Coagulation Factor VIII Complex (Human) concentrate was given postdelivery to counter the expected rapid decrease in vWF activity postdelivery (40 units/kg 1 h postdelivery then 20 units/kg 12 h after delivery) to ensure that vWF activity was greater than 50% prior to pulling the epidural catheter and 24 h thereafter. Subsequently, vWF/Coagulation Factor VIII Complex (Human) concentrate 20 units/kg daily was continued daily for 10 days (in hospital and at home). In addition, tranexamic acid 750 mg three times a day by mouth was also started postdelivery. The patient had an uncomplicated spontaneous vaginal delivery and successful epidural placement/removal with no untoward bleeding or neuraxial complications.
Figure 1: Final agreed peripartum management plan at prepartum multi-disciplinary conference

Click here to view



  Discussion Top


Bleeding diatheses can pose great risks to patients in the peripartum setting, leading to serious complications such as postpartum hemorrhage or epidural hematoma. It is imperative for clinicians to be fully aware of the underlying bleeding diatheses so as to formulate an agreed upon management plan to ensure appropriate and uneventful patient care like our patient with two inherited bleeding diatheses, VWD and platelet storage pool disease (PSPD). VWD is a common inherited bleeding diathesis with prevalence ranging from 0.0023% to 1.3% depending on the diagnostic criteria. [3] PSPD is a rare disorder involving defects in platelet granule storage/secretion leading to abnormal aggregation and activation of platelets. There have been few documented cases of pregnant patients with this disorder. [4] Due to this patient's increased risk for epidural hematoma due to hypo-functioning platelets, she required donor platelets prior to placement and removal of the epidural catheter with additional monitoring and management of vWF activity postdelivery.

In our institution, these formal multi-disciplinary preoperative meetings involving the anesthesiology personnel are infrequent but not rare. They most commonly occur in our obstetric anesthesia setting such as for perioperative management plan for placenta percreta that additionally involves interventional radiologists for internal iliac arterial balloon insertion and management, urologists for ureteral stent placement and gynecologic oncology for cesarean hysterectomy besides anesthesiologists, obstetricians, pathologists, blood bank personnel, pediatrics, maternal fetal medicine along with the patients and their families. Similar to the abovementioned case, consortium of various specialties along with the patients and their families preoperatively all under one roof can assure that all involved parties can raise their concerns that can be answered immediately and ideas can be freely conveyed and critiqued in an open forum to decide upon an agreeable perioperative management plan. This immediate line of communication among different specialties can provide a more thorough and properly vetted treatment options rather than if all relevant parties operated and decided independently. Furthermore, these meetings can provide forewarning of potential material supplies that may need to be set aside or ordered [[Figure 1]: Item nos. 8-10]. In the present case, blood bank services were notified well in advance about the need for blood; platelets and vWF/Coagulation Factor VIII Complex (Human) concentrate. Pharmacy can also be notified when less commonly used drugs will be required like tranexamic acid.

Multi-disciplinary team approach has been studied in other surgical fields with positive outcomes. A study from 2006 compared outcomes of patients recently diagnosed with esophageal cancer. [5] One group was treated by only primary surgeons and the other group by a team consisting of a consultant anesthesiologist and two consulting surgeons. Data showed many improved benefits from the multi-disciplinary approach including improved mortality, better initial staging, few surgical interventions required and few surgical complications. Other surgical teams including transplant services also understand the importance of a multi-disciplinary approach with inclusiveness of anesthesia personnel. [6] Another potential advantage of these multi-disciplinary meetings is to reduce errors caused by hand-offs. On labor and delivery floors of most hospitals, the anesthesia providers and obstetricians can vary from day-to-day (and sometimes shift-to-shift), which can allow important information to be missed increasing the risk of avoidable events. Establishing a clear perioperative (or peripartum) plan and permanently placing in patient's medical record (with possible bedside handouts/displays) may help reduce these potentially catastrophic situations in known difficult patient care scenarios. For example, from anesthesia standpoint, risk for epidural hematoma was drastically increased in our patient due to her bleeding diatheses that made timing of platelet infusions and epidural catheter insertion/removal extremely important [[Figure 1]: Item no. 6]. Similarly, from obstetric standpoint, avoiding invasive monitoring and interventions for our parturient patient was key to prevent unnecessary bleeding [[Figure 1]: Item no. 5]. It is important to appreciate that how easily small miscommunications with catastrophic results and/or inadequate medical care for these patients can happen if there are no clear cut management plans to follow across the various obstetric and anesthesia care providers that manage these difficult and rare disease patients over the short span of peripartum days.


  Conclusion Top


In summary, anesthesiologists as perioperative physicians are in a unique position to actively participate in multi-disciplinary approach to perioperative patient care. Complex patient scenarios wherein multiple clinicians are concurrently managing these patients can benefit the most from this approach. The authors are hopeful that the future will see more of such collaborative meetings as a widely adopted standard of care for management of all difficult perioperative patients.

 
  References Top

1.
Keating NL, Landrum MB, Lamont EB, Bozeman SR, Shulman LN, McNeil BJ. Tumor boards and the quality of cancer care. J Natl Cancer Inst 2013;105:113-21.  Back to cited text no. 1
    
2.
Henson DE, Frelick RW, Ford LG, Smart CR, Winchester D, Mettlin C, et al. Results of a national survey of characteristics of hospital tumor conferences. Surg Gynecol Obstet 1990;170:1-6.  Back to cited text no. 2
    
3.
Nichols WL, Hultin MB, James AH, Manco-Johnson MJ, Montgomery RR, Ortel TL, et al. von Willebrand disease (VWD): Evidence-based diagnosis and management guidelines, the National Heart, Lung, and Blood Institute (NHLBI) Expert Panel report (USA). Haemophilia 2008;14:171-232.  Back to cited text no. 3
    
4.
Jewell M, Magann EF, Barr A, Baker R. Management of platelet storage pool deficiency during pregnancy. Aust N Z J Obstet Gynaecol 2003;43:171-2.  Back to cited text no. 4
    
5.
Stephens MR, Lewis WG, Brewster AE, Lord I, Blackshaw GR, Hodzovic I, et al. Multidisciplinary team management is associated with improved outcomes after surgery for esophageal cancer. Dis Esophagus 2006;19:164-71.  Back to cited text no. 5
    
6.
Yosaitis J, Manley J, Johnson L, Plotkin J. The role of the anesthesiologist as an integral member of the transplant team. HPB (Oxford) 2005;7:180-2.  Back to cited text no. 6
    


    Figures

  [Figure 1]



 

Top
 
 
Search
Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)  

 
  In this article
Abstract
Introduction
Case Report
Discussion
Conclusion
References
Article Figures

 Article Access Statistics
    Viewed3017    
    Printed48    
    Emailed0    
    PDF Downloaded206    
    Comments [Add]    

Recommend this journal